Provider Demographics
NPI:1306845789
Name:PERENCHIO, CAROL (NP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:PERENCHIO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 E BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7102
Mailing Address - Country:US
Mailing Address - Phone:815-477-9577
Mailing Address - Fax:
Practice Address - Street 1:934 CENTER ST
Practice Address - Street 2:SHERMAN HOSPITAL EMERGENCY DEPARTMENT
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60120-2125
Practice Address - Country:US
Practice Address - Phone:847-429-8750
Practice Address - Fax:847-429-8978
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209000834363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK14481Medicare PIN
ILP00327773Medicare PIN
ILK14482Medicare PIN